1. Kupperschmidt, Betty R. EdD, RN

Article Content

Nurse managers are expected to be accountable for staff nurse job satisfaction, including providing cohesive work groups 1,2 and explaining nurses' organizational roles and helping them to find purpose and meaning in their work. 3 If staff nurses fail to achieve these satisfiers, have nurse managers failed to do their jobs? Is it more appropriate for staff nurses and managers to share the accountability for job satisfaction? The purpose of this article is to present the case for shared accountability. The contrasting (and prevailing) view is the continued burden of staff nurse satisfaction being on managers, with an attendant misguided entitlement of staff nurses.


Misguided Entitlement

Misguided entitlement is an exaggerated sense of self-importance, value, and specialness. 4 For example, during a previous nursing shortage, economic incentives and recruitment strategies and nurses' ensuing expectation of job security despite lack of accountability for patient outcomes and professional behaviors could be considered misguided entitlement. 5 Misguided entitlement is a change-resistant, interrelated pattern of behaviors and the belief that one must and will be treated in a special way. It is a mismatch between wants and expectations and what is reasonable under prevailing circumstances. Consequences include diminished initiative and failure to develop coping strategies and requisite skills to develop positive interpersonal relationships. 4


Staff nurse job satisfaction should be achieved through shared accountability. 6 Accountability means being responsible and accountable to self and others for behaviors and outcomes included in one's professional role: A professional nurse is accountable for embracing professional values, maintaining competence, and maintenance and improvement of professional practice environments. 6


Professional nurses are ethically responsible for respectful interactions and professional work environments, factors that should result in cohesive work groups and enhanced job satisfaction. 1,2 Nurse administrators are advised to address individual staff nurses' personal esteem and professional worth, find ways to reward and recognize individual staff contributions, and develop multi-option retention strategies that encompass expectations of nurses of all ages. 1,2 Although these are worthwhile goals, there must also be strategies that address nurses' accountability for cohesive work groups. For example, staff nurses often value coworker recognition more highly than manager recognition; thus, professional staff nurses should be accountable for using a variety of strategies to recognize coworker contributions, thus facilitating job satisfaction for themselves and coworkers. 7 Until achieving cohesive work groups becomes a shared accountability, with staff as active participants, staff have permission to ignore this ethical accountability.


Nurses report higher levels of personal empowerment if managers foster their perceptions of autonomy, confidence, and the meaningfulness of their work. 3 According to the ANA Code of Ethics, competence and continued personal and professional growth affect self-respect, self-esteem, professional status, and meaningfulness of work. 6 Is professional nurses' lack of accountability for competence, without managerial intervention, another example of misguided entitlement and a causative factor in nurses' inability to find meaning and purpose in the work of nursing?


Managed care and staff nurses' inability to understand managed care is cited as the cause of nurses' inability to cope with uncertain work environments and provide high-quality nursing care. 7,8 Professional behaviors are not promoted when nurses are continually defined in terms of their least resourceful conditions, such as inability or unwillingness to trust administration and provide professional care in uncertain environments or understand managed care without managerial interventions. 9 Rather, misguided entitlement is fostered.


Brandon 9 asserts it is past time to challenge the underlying principle of entitlement, the doctrine that some people have an unearned claim on the mind, energy, and effort of others. Entitlement treats people as means to the ends of others and asserts the moral right to do so. True community and collegial relationships suffer when professionals abdicate their responsibilities to someone and that someone accepts them. 9 When nurse managers justify their jobs by assuming staff nurses' responsibilities, it is usually because both parties perceive permission from some authority to do so. Is this permission the prevailing rhetoric of nurse managers' accountability for staff nurse outcomes, rather than shared accountability?


When responsible adults refuse to share accountability, it poisons human relationships, corrupts professions, and makes self-esteem impossible. Refusal to share accountability with responsible adults is morally corrupting, psychologically disempowering, and spiritually devaluing and dehumanizing. Brandon argues that moral responsibility and accountability are integral to human dignity, and shared accountability moves employees from being victims to being personally empowered. 9 Outcomes in today's complex organizations can not be obtained and sustained through the efforts of one individual; they must be obtained through the interface and responsible participation of all on whom the outcomes depend. Excessive focus on managers' accountability for staff nurses' job satisfaction promotes misguided entitlement rather than professional accountability. It is time to champion shared accountability, the ethical imperative of professional staff nurses and managers.


Fostering Shared Accountability

DePree 10 conceptualizes shared accountability as the marvelous gift leaders and employees must share. He contends that sharing this gift frees the spirit because adults naturally understand, want, and expect to be held accountable for their choices and actions. How can staff nurses and nurse managers begin to share accountability for staff nurses' job satisfaction? Staff nurses must ask why they accept the prevailing rhetoric: Is it because they like their current roles and prefer that managers assume the accountability? Managers must ask the same question: Do they like their roles as boss? 11


Nurse managers and administrators must acknowledge their ethical accountability for professional practice environments within a model of shared accountability. Educators must assure that students understand their ethical imperative to embrace the ANA Code of Ethics and attendant roles as professionals in fostering professional practice environments. Teaching strategies related to team building must foster "followership" and individual accountability for cohesive teams and work groups. Nurse researchers must recommend strategies that promote shared accountability.


Finally, each professional nurse should purposefully reflect upon the intent and essence of the Code of Ethics and the insidious erosion of individual professional accountability posed by misguided entitlement. All nurses must question the extent to which their failure to confront this prevailing rhetoric perpetuates misguided entitlement. When a person chooses to become a professional nurse, he or she accepts the responsibility to uphold the values of the profession: A powerful, poignant incentive to confront misguided entitlement. During a previous nursing shortage, shared accountability was achieved as work outcomes were clarified, compensation was tied to performance, and authority was delegated proportionate to employee readiness for decision-making power. 5


Currently, acute care facilities are implementing shared leadership models. These models are nursing management models that support and expect staff nurse input into decisions that affect their practice, work environments, professional development, and self-fulfillment. These models, based upon the pillars of accountability, partnership, equity, and ownership, empower, support, and expect staff nurses to act autonomously at the point of service. 11,12


One organization reports using a shared leadership council to create and maintain a relationship-based environment that supports peer-to-peer accountability, retention, and staff nurse job satisfaction. This shared leadership model embraces the principle of shared work, sharing the accountability to create and maintain healthy work relationships, provide quality care, and continuous learning. 11


Another organization uses a shared leadership model based in part on motivational and self-efficacy theory. Staff nurses receive education that promotes development of critical leadership qualities, including change facilitation, decision making, and negotiating win-win solutions to achieve improved patient and staff nurse outcomes. 12


Connors et al 13 developed a model based upon the lesson Dorothy and companions learned on their journey to Oz: People hold within themselves the power to rise above their circumstances. With this model, staff nurses and managers jointly take a proactive stance, acknowledge shifted accountabilities, and commit to sharing accountability for work environments and job satisfaction. Specific strategies include seeking and using feedback, focusing on what must and can be changed, and embracing stewardship, a sense of ownership for a professional work environment. 13



Less than 2 decades ago, nurse managers were advised to stop babying nurses and refining parenting leadership to a high art. These managerial actions purportedly prevented cohesive teams and fostered codependency and oppressive conditions in nursing. 14,15 Today, staff nurses are reportedly ready to create work environments that support them as accountable, knowledgeable workers. 11,15 Will failure to support this readiness promote psychologically disempowering work environments and more deeply embed misguided entitlement? Will staff nurses assume their ethical accountability for job satisfaction and supportive work environments if repeatedly told it is the manager's responsibility or managers must "do something in order to get them to?"


These are critical questions worthy of consideration and dialogue. The pervasive and almost religious belief in and dependence upon leaders to bring valued outcomes into the workplace must be replaced with shared accountability. Creating preferred conditions of employment is not a solo or spectator sport. The specialness of professional nurses must be validated through strategies that promote professionalism rather than misguided entitlement, beginning with shared accountability for job satisfaction.




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